Healthcare Provider Details

I. General information

NPI: 1497084255
Provider Name (Legal Business Name): BRANCE E. HAGOOD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W BROADWAY ST SUITE A
ROGERSVILLE TN
37857-3280
US

IV. Provider business mailing address

215 W BROADWAY ST SUITE A
ROGERSVILLE TN
37857-3280
US

V. Phone/Fax

Practice location:
  • Phone: 423-272-2345
  • Fax: 423-272-3324
Mailing address:
  • Phone: 423-272-2345
  • Fax: 423-272-3324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD0000001413
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberOD001413
License Number StateTN

VIII. Authorized Official

Name: DR. BRANCE EDWIN HAGOOD
Title or Position: OWNER
Credential: O.D.
Phone: 423-272-2345